Nov 3 2010 15:22 1l/ag/28le 16:19 8589218158 PAGE 8/17 Wi? TATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case Nos. 2010009694 Vs. INGLESIDE RETIREMENT, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against Ingleside Retirement (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2009), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of eight thousand dollars ($8,000.00) based upon two (2) State Class II deficiencies pursuant to § 429.19(2)\(b). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§.20.42, 120,60 and.Chapters 408, Part 0, and 429, Part I, Florida Statutes (2009). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable ‘state statutes and rulcs governing assisted living facilities pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter Nov 3 2010 15:23 1l/ag/28le 16:19 8589218158 PAGE 9/17 58A-5, Florida Administrative Code. 4, Respondent operates an 18-bed assisted living facility located at 1433 Ingleside Avenue, Jacksonville, Florida 32205, and is licensed as an assisted living facility, license number 5576, 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. , 7. That pursuant to Florida law, every facility shall be under the supervision of an administrator who is responsible for the operation and maintenance of the facility including the management of all staff and the provision of adequate care to all residents as required by Part I of Chapter 429, F.S., and this rule chapter. (a) The administrators shall: ]. Be at least 2] yeats of age: 2. Ifemployed on or after August 15, 1990, have a high school diploma or general - equivalency diploma (G-E.D.), or have been an operator or administrator of a licensed assisted living facility in the State of Florida for at least one of the past 3 years in which the facility has met minimum standards, Administrators employed on or after October 30, 1995, must have a high school diploma or G.E.D.; 3. Be in compliance with Level 2 background screening standards pursuant to Section 429.174, FS.; and ; 4. Complete the core training requirement pursuant to Rule 584-5.0191, F.A.C. (b) Administrators may supervise a maximum of either three assisted living facilities ot a combination of housing and health care facilities or agencies on a single campus. However, administrators who supervise more than one facility shall appoint in writing a separate “manager” for each facility who must: 1. Be at least 21 years old; and Nov 3 2010 15:23 1l/ag/28le 16:19 8589218158 PAGE 18/17 2. Complete the core training requirement pursuant to Rule S8A-5.0191, RAC. (c) Pursuant to Section 429.176, F.S., facility owners shall notify both the Agency Field Office and Agency Central Office within ten (10) days of a change ina facility administrator on the Notification of Change of Administrator, AHCA Form 3180-1006, January 2006, which is incorporated by refetence and may be obtained from the Agency Central Office. The Agency Central Office shall conduct a background screening on the new administrator in accordance with Section 429.174, F.S., and Rule 58A4-5.014, F.A.C, Fla. Admin. Code R. 58A-5.019(1) 8. That on December 7, 2009, the Agency conducted an unannounced complaint investigation (CCR# 2009013613) of the Respondent’s facility. 9. That based on record review and staff and resident interview, the Assisted Living Facility (ALF) failed to ensure there was a functioning administrator in place within the ALF who was responsible for the operation and maintenance of the facility and the safety of residents, 10. That the surveyor arrived at the ALF on 12/07/2009 at 9:05 am. to commence a complaint investigation, and requested the staff person who opened the door to get the ALF Administrator. The surveyor was informed the Administrator was in New Jersey. The surveyor requested to speak to the person in charge, and was informed the ALF Manager was not in the building, and no one else was designated in charge, At 9:15 a.m. the surveyor introduced herself and the agency to the 2nd employee on site, who at first refused to give his name, and stated he was not responsible for the facility. At 9:55 am. on 12/07/2009 the ALF Manager arrived after being called by the staff on duty. 1h. That the surveyor spoke with three ALF residents on 12/07/2009. Resident #1 who had been living in the facility for ten years was interviewed at 10:10 am., and stated the administrator had noi been working in the ALF for at least three (3) months-or more. Resident Nov 3 2010 15:23 17 1l/ag/28le 16:19 8589218158 PAGE 11/ #2 was intervicw at 11:05 a.m. and stated he/she had been in the facility since 9/30/2009, and had never heard of the person the surveyor mentioned as the ALE Administrator. Resident #3 was interviewed at 11:55 am. and has been in the ALF since 2005, and stated the administrator/employee mentioned by the surveyor had not been working in the ALF for three months or more. All three residents were alert and orented, and two of them were recommended by the ALF Manager and ALF owner as alert and oriented for interviews 12. That the surveyor interviewed on 12/07/2009 at 10:40 am. a case manager from a mental health agency who was on site working with residents, who stated he had been coming to the facility five days a week, from 10:00 am, to 12:00 p.m. since the first of October 2009, and had never seen, met or heard of the ALF administrator meritioned by the surveyor. 13. That an interview with the ALF Manager on 12/7/2009 at 9:55 am. who stated she had taken the ALF Core training on 7/13/2009, but had not taken the ALF Test, as she was not 21 years of age at the time. She stated she tumed 21 years of age on 10/27/09, but was still not scheduled to take the ALF Core Training Test at this time. The ALF Manager stated the former Administrator was out of state, and had been for a while. A review of the ALF work schedules on 12/7/2009 revealed the former ALF Administrator had not beon listed on the partial August, September, and November 2009 work schedules that were provided to the surveyor. The October 2009 work schedule was not available at all. The December work schedule listed the former ALF Administrator as working the first three weeks in December 2009 including 12/7/2009. The ALF Manager stated the schedules were not accurate as the former Administrator was not available. 14. That an interview with the ALF owner on 12/07/2009 at 10-50 a.m. confirmed the former ALF Administrator was not on site, and had gone to New Jersey for family/personal reasons, and had not been in the facility for approximately three months. The ALF owner was not sure of the Nov 3 2010 15:24 1l/ag/28le 16:19 8589218158 PAGE 12/17 date. The ALF owner stated there had been no Administrator on site since then, and scemed unaware the current ALF Manager was not qualified to act as administrator of the facility, and had not been 21 years of age until the end of October. 15. That the surveyor reviewed resident, personnel and facility records briefly during the complaint visit, and found incomplete or inaccurate resident Medication Observation Records, unsecured medications, incomplete or inaccurate staffing schedules, staff unaware of who was in charge, and unqualified administrative staff in charge. 16. That for the period of time September through December 7, 2009 there had been no qualified ALF Adtninistrator in place at the ALF to admit/discharge residents, supervise delivery of resident services, maintain records and oversee operations. 17, That Class “II” violations are those conditions or occutrences related to the operation and maintenance of a provider or to the care of clients which the agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. The agency shall impose an. administrative fine as provided by law for a cited class If violation, A fine shall be levied notwithstanding the correction of the violation. 18. That the Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2009). 19. That the Agency provided a mandatory correction date of December 10, 2009. WHEREFORE, the Agency intends to impose an administrative fine in the amount of three thousand dollars ($3,000.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(b), Florida Statutes (2009). COUNT II 20. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth Nov 3 2010 15:24 11/83/2818 15:19 8589218158 PAGE 13/17 herein. 21, That pursuant to Florida Jaw, the facility shall maintain a daily medication observation record (MOR) for each resident who receives assistance with self-administration of medications or medication administration. A MOR, must include the name of the resident and any known allergies the resident may have; the name of the resident’s health care provider, the health care provider’s telephone nurnber; the nate, strength, and directions for use of each medication; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The MOR must be immediately updated each time the medication is offered or administered. Fla. Admin. Code R, 58A-5.0185(5(b)) 22. That on December 7, 2009, the Agency conducted an unannounced complaint investigation (CCR# 2009013613) of the Respondent’s facility. 23, That based on record review and staff interview, the Assisted Living Facility (ALF) failed to adequately monitor and update resident medications on the Medication Observation Record (MOR) as they were given for 12 of 12 ALF residents who get assistance with medications, #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, 411, #12. 24, That on 12/7/2009 during a complaint investigation visit, the surveyor requested from the ALF Manager in charge the current MOR. book whete resident medications were recorded and initialed by staff. The surveyor observed Resident #1's December 2009 Medication Observation Record (MOR) had not been updated and initialed by staff as to the medications given after Thursday 12/3/2009, There was no documentation by staff for the Monday 12/7/2009 moming medications either. A review of the ALF medication book for the twelve (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12) residents receiving assistance with medications by facility staff, revealed none of the twelve ALF residents had documentation that their medications had been Nov 3 2010 15:24 1l/ag/28le 16:19 8589218158 PAGE 14/17 given from Friday morning 12/4/2009 through Monday motming 12/7/2009. When this issue was brought to the attention of the ALP Manager in charge, she was unaware the medications had not been documented for that period. She stated the medications had been given, but no one had documented and initialed that it had been done. 25. That a review of the medications prescribed for the residents of this ALF that were nol documented as given included the psychotropic medications Clozapine, Risperidone, Haloperidol for five different residents, Fluoxetine (depression). for three other residents, as well as Metformin (diabetes), and Lopressor (aypertension), Lisinopril (hypertension), Plavix (antiplatelet), Diltiazem (hypertension) ‘and other critical medications for residents with cardiovascular diseases. 26. That Class “II” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines directly threaten. the physical or emotional health, safety, or security of the clients, other than class I violations. The agency shall impose an administrative fine as provided by law for a cited class II violation. A fine shall be levied notwithstanding the correction of the violation. 27, ‘That the Agency cited the Respondent for a Class TI violation in accordanee with Section 429.19(2)(b), Florida Statutes (2009), 28. ‘That the Agency provided a mandatory comection date of December 10, 2010. . WHEREFORF, the Agency intends to impose an administrative fine in the amount of five thousand dollars ($5,000.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(b), Florida Statutes (2009). Nov 3 2010 15:24 1l/ag/28le 16:19 8589218158 PAGE 15/17 CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Counts I through II (B) Recommend administrative fines against Respondent in the amount of $8,000; (C) Assess attomney’s fees and costs: and . (D) Grant all ether general and equitable relief allowed by law. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights form. All tequests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873, RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted thiseaf ‘ay of September, 2010, arlton Enfinger Fla. Bar.0793450 Agency for Healt 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.412.3640 (office) 850.921.0158 (fax) Nov 3 2010 15:25 11/83/2818 16:19 85892148158 PAGE 16/17 CERTIFICATE OF SERVICE THEREBY CERTIFY that a true and cortect copy of the foregoing has been served by U.S. Certified Mail, Retum Receipt No. 7001 0360 0003 3808 3048 to Facility Administrator Stacy Wilson, Ingleside Retirement, 1433 Ingleside Avenue, Jacksonville, Florida’ 32205 on September 220 10: bs Le Carlton Enfinger Copy furnished to: Robert Dickson, FOM Nov 3 2010 15:25 1l/ag/28le 16:19 8589218158 PAGE 17/17 ihe aclu rib dpe Ee a a Cane : a S atte U:S, Postal Serv ee oe GERTIFIED: MAIL. RECEIPT ( bs f dia Mie ta od uh ae b Fat ud vonage [8 : bee thai: I jeu eat rates ae : A Oia wt oe 4 Ry pe an ae ak eae Gartifiad Fes Hatedind ae a i ‘a Return Reogipt Fea Baad Stn a : gee (Endorsement Require) Senoe, ae nN i . Fe yma if Be Snir . Restricted Dellvary.Fee enh * SES Rete ene on {Endorsement Required} Reentry sae Ri 7 Total Postage & Fase i oy a oe ie i ee ats et PR ae me : + ‘ Ky Ce es 89 Seth Ste, An cht Street, Apt Nod _ oe erenennn ie ar PO Box No. y i EA ali bah dee IRE eos ae " ae ns me a oS 8 — TNS FANS et ms ae Roniiaetatint fieB CAE Le een Sac ick i 4 et é dice Cree ke a wi eae SACI EE, ‘ih ee ies e Uae . dR aes lag nee ae ee ae e cae ey ee i ath ‘ SS Rath at pene a en Me a ie rat wee ak : re eon yes ag sie i Sea ee Stein Be Seda ee ci 4 Be ae Rony Catan ne a cae Radiesse a ge Sn ew ett eae ig ae 8 ae ne aN eae oe. a ve : S me is rae ne ae ee ee Le Cees GE Sete oe s cay ce i SR 5 ake i A eh, no, x gitgolts es Coe wan ee ne ee oe al Coan] Complete items 1, 2, and 3, —S Also completa i at it et ‘ item 4 if Restricted Delivery Is desired Pr Rue Print your namé and-addrasg.on the reverse 80 that we can retum the card fo you. —# ois a a te i Attach this card to the back of tha mailpiece, 8. Reosived by ( Prstec 2 . : ue e ae ‘ : : or on the front If apace permits. Lo" Lae o 1. Article Addressed tor D. Is delivery address differant from ttem 7? [1] Yes Race tatt if YES, enter delivery address below: 1 No he ea ie | oss WING. Adon Latico ier Yaa CWohe, Feklisiaun TT $ Cngie ky, Ae Bh, a JR 7 i OR i h oi : Jeclues te Ra? Oe CT ingureei Mail Doon Ressint or Merchandise ; a oe Ne SS o 4 Rostioted Delivery? (Extra Fee) See : oe He - a ue 0740 Goo3 3408 snug hh es td ry oe Bs * mar te ent om SERRE YE gar “andar mam oo ies ema ah i ee rat a i GAME ee Craton Sta tephra Sete won as et ae re ay a oe AE eR a ee rae debate sei esi TOES aie amy "f es oe o a i ue De ee a ae a Hf re saat nen ion ae i ae an i is i colar ota CG PEALE “g 3 aan ie Te RES cans me a ie a es a o - Sie ae Shs si) als ike ARG sha ee ‘ ‘ neat dager ais say y sy ecg A iy eidet By an * ¥; oe ee ih oe ee Ane i ee a oe ees ae os " ee

Docket for Case No: 10-010068